Provider Demographics
NPI:1477259919
Name:FANT, LIZA MONIQUE (LPC-A)
Entity Type:Individual
Prefix:
First Name:LIZA
Middle Name:MONIQUE
Last Name:FANT
Suffix:
Gender:F
Credentials:LPC-A
Other - Prefix:
Other - First Name:LIZA
Other - Middle Name:M
Other - Last Name:FANT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:7351 DEL SOL WAY
Mailing Address - Street 2:
Mailing Address - City:CANUTILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79835-6103
Mailing Address - Country:US
Mailing Address - Phone:915-301-9779
Mailing Address - Fax:
Practice Address - Street 1:7351 DEL SOL WAY
Practice Address - Street 2:
Practice Address - City:CANUTILLO
Practice Address - State:TX
Practice Address - Zip Code:79835-6103
Practice Address - Country:US
Practice Address - Phone:915-301-9779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX83527101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor